Admission Computed Tomography Scan Research Articles

Clinical Significance of the Control CT Rotterdam Score Compared With the Admission CT Rotterdam Score in Patients With Isolated Severe Traumatic Brain Injury in the Intensive Care Unit.

The Rotterdam scale is one of the most commonly used radiological scales for evaluating and predicting outcomes in traumatic brain injury (TBI) cases. Given the evolving nature of TBI, our study is designed to compare the Rotterdam score of computed tomography (CT) findings upon admission (Rotterdam score I) with the score after 72 hours (Rotterdam score II) of treatment in the trauma intensive care unit (ICU). A retrospective observational study was conducted on 54 patients who received intensive care treatment for isolated severe TBI over five years. We included severe TBI patients with no age restrictions who required admission to the ICU within 12 hours of the onset of trauma. An initial Rotterdam CT score was obtained via a CT head scan within four hours of the trauma, followed by a control CT head scan 72 hours after ICU admission. It was essential to have documentation on the clinical and laboratory treatment course and access to radiological CT diagnostics. Receiver operating characteristic (ROC) curves were employed in this study to evaluate the accuracy of diagnostic tests, such as the Rotterdam score. The ROC curves provided a graphical representation of the tests' diagnostic performance, which helped assess their effectiveness. There was a significant difference (p < 0.001) in the diagnostic scores of CT scans upon admission (Rotterdam score I) and control CT scans after 72 hours (Rotterdam score II) in the total sample. The Rotterdam score I was notably higher, 3.6 (±0.8), in patients requiring neurosurgical intervention compared to those who did not, 2.8 (±0.9), with significance (p = 0.003). The Rotterdam score I demonstrated a substantial predictive value for unfavorable outcomes (p = 0.048), as did the Rotterdam score II after the 72-hour mark (p = 0.006). The control Rotterdam score 72 hours after admission predicts mortality in isolated TBI patients more significantly than the Rotterdam score determined at the patient's admission to the intensive care unit.

Volumetric Assessment of Traumatic Intracranial Hematomas: Is ABC/2 Reliable?

Accurate measurement of traumatic intracranial hematoma volume is important for assessing disease progression and prognosis, as well as for serving as an important end-point in clinical trials aimed at preventing hematoma expansion. While the ABC/2 formula has traditionally been used for volume estimation in spontaneous intracerebral hemorrhage, its adaptation to traumatic hematomas lacks validation. This study aimed to compare the accuracy of ABC/2 with computer-assisted volumetric analysis (CAVA) in estimating the volumes of traumatic intracranial hematomas. We performed a dual-center observational study that included adult patients with moderate-to-severe traumatic brain injury. Volumes of intracerebral, subdural (SDHs), and epidural hematomas from admission computed tomography scans were measured using ABC/2 and CAVA, and compared using the Wilcoxon signed-rank test, Spearman's rank correlation, Lin's concordance correlation coefficient (CCC), and Bland-Altman plots. Prognostic significance for outcomes was evaluated through logistic and linear regression models. In total, 1,179 patients with 1,543 hematomas were included. Despite a high correlation (Spearman coefficients between 0.95 and 0.98) and excellent concordance (Lin's CCC from 0.89 to 0.96) between ABC/2 and CAVA, ABC/2 overestimated hematoma volumes compared with CAVA, in some instances exceeding 50 ml. Bland-Altman analysis highlighted wide limits of agreement, especially in SDH. While both methods demonstrated comparable accuracy in predicting outcomes, CAVA was slightly better at predicting craniotomies and midline shift. We conclude that while ABC/2 provides a generally reliable volumetric assessment suitable for descriptive purposes and as baseline variables in studies, CAVA should be the gold standard in clinical situations and studies requiring more precise volume estimations, such as those using hematoma expansion as an outcome.

Abdominal computed tomography scoring systems and experienced radiologists in the radiological diagnosis of small bowel and mesenteric injury

PurposeBlunt bowel and/or mesenteric injury requiring surgery presents a diagnostic challenge. Although computed tomography (CT) imaging is standard following blunt trauma, findings can be nonspecific. Most studies have focused on the diagnostic value of CT findings in identifying significant bowel and/or mesenteric injury (sBMI). Some studies have described scoring systems to assist with diagnosis. Little attention, has been given to radiologist interpretation of CT scans. This study compared the discriminative ability of scoring systems (BIPS and RAPTOR) with radiologist interpretation in identifying sBMI.MethodsWe conducted a retrospective chart review of trauma patients with suspected sBMI. CT images were reviewed in a blinded fashion to calculate BIPS and RAPTOR scores. Sensitivity and specificity were compared between BIPS, RAPTOR, and the admission CT report with respect to identifying sBMI.ResultsOne hundred sixty-two patients were identified, 72 (44%) underwent laparotomy and 43 (26.5%) had sBMI. Sensitivity and specificity were: BIPS 49% and 87%, AUC 0.75 (0.67–0.81), P < 0.001; RAPTOR 46% and 82%, AUC 0.72 (0.64–0.79), P < 0.001; radiologist impression 81% and 71%, AUC 0.82(0.75–0.87), P < 0.001. The discriminative ability of the radiologist impression was higher than RAPTOR (P = 0.04) but not BIPS (P = 0.13). There was not a difference between RAPTOR vs. BIPS (P = 0.55).ConclusionRadiologist interpretation of the admission CT scan was discriminative of sBMI. Although surgical vigilance, including evaluation of the CT images and patient, remains fundamental to early diagnosis, the radiologist’s impression of the CT scan can be used in clinical practice to simplify the approach to patients with abdominal trauma.

Clinical findings of acute necrotizing esophagitis complicated by diabetic ketoacidosis.

Acute necrotizing esophagitis (ANE) is a rare and potentially life-threatening complication of diabetic ketoacidosis (DKA). While its association with DKA is established, specific clinical characteristics that predict ANE in DKA patients remain less understood. This study aimed to identify these characteristics by analyzing data from 30 DKA patients admitted from January 2018 to September 2022. Seven patients in this study presented with ANE, forming the ANE group. The remaining 23 constituted the non-ANE group. We compared the clinical parameters and computed tomography (CT) between the groups. The mean age of participants was 57.7 ± 20.4 years, and their mean HbA1c was 11.1 ± 3.3%. Notably, ethanol intake was significantly higher in the ANE group (44.4 ± 25.4 g/day) compared to the non-ANE group (6.8 ± 14.0 g/day; p = 0.013). Additionally, sodium-glucose transport protein 2 inhibitor use was significantly more prevalent in the ANE group (p = 0.013). Gastrointestinal symptoms were also significantly more pronounced in the ANE group, with vomiting occurring in 85.7% of patients compared to only 13.0% in the non-ANE group. Admission CT scans revealed further distinguishing features, with the ANE group showing significantly higher rates of esophageal wall thickening, intra-esophageal effusion, and calcification of the celiac artery origin (p < 0.0001, 0.0038, 0.0038, respectively). In conclusion, our study suggests that heavy alcohol consumption and strong gastrointestinal symptoms in DKA patients warrant a heightened suspicion of ANE. Early consideration of CT or upper gastrointestinal endoscopy is recommended in such cases.

Cilostazol May Improve Outcomes Even in Patients with Aneurysmal Subarachnoid Hemorrhage Aged 75 Years and Older: Multicenter Cohort Study and Propensity Score–Matched Analyses

The opportunities to treat elderly patients with aneurysmal subarachnoid hemorrhage (aSAH) are increasing globally, but the outcome remains poor. This study seeks to investigate treatment-related factors that can modify functional outcomes in patients with aSAH aged ≥75 years. A total of 202 patients with aSAH aged ≥75 years prospectively enrolled in 9 primary stroke centers from 2013 to 2021 were retrospectively analyzed. Clinical variables including treatments for hydrocephalus, angiographic vasospasm, and delayed cerebral ischemia were compared between patients with good (modified Rankin Scale [mRS] score 0-2) and poor (mRS score 3-6) outcomes at 90 days from onset, followed by multivariate analyses to find independent outcome determinants. A modifiable treatment-related variable was evaluated after propensity score matching with adjustments for age, sex, pre-onset mRS score, aSAH severity, and treatment modality. More than half of patients showed World Federation of Neurological Societies grades IV-V on admission. Univariate analyses showed that advanced age, worse pre-onset mRS score, more severe neurologic status on admission, higher modified Fisher grade on admission computed tomography scans, and acute and chronic hydrocephalus were associated with poor outcomes. In contrast, administration of a phosphodiesterase type III inhibitor, cilostazol, was associated with good outcomes in both univariate (P= 0.036) and multivariate analyses (adjusted odds ratio, 0.305; 95% confidence interval, 0.097-0.955; P= 0.042). Propensity score matching analyses showed that patients treated with cilostazol had better outcomes (P= 0.016) with fewer incidences of delayed cerebral infarction (P= 0.008). Even in patients with aSAH aged ≥75 years, cilostazol administration may lead to better outcomes by suppressing the development of delayed cerebral infarction.

Blunt Pulmonary Contusion: Admission Computed Tomography Scan Predicts Mechanical Ventilation

INTRODUCTION Road traffic injury is one of the fastest growing health problems in Nepal with increasing number every year leading to morbidi- ty and mortality. Blunt pulmonary contusion may not be seen in the initial plain radiographs as they evolve over 12-24 hours. Thus CT (Computed Tomography) scan can provide detailed information about the contusion and predict the need for mechanical ventilation. MATERIAL AND METHODS This is a prospective, observational longitudinal study conducted at Universal College of Medical Sciences, Bhairahawa from 1st January 2020 to 31st December 2020. The predictors for requirement of mechanical ventilation like Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), GCS score and number of fractured ribs at the time of admission were recorded. RESULTS In this study, 100 cases with blunt pulmonary contusion were evaluated. Average age of patients with blunt pulmonary contusion was around 39.10±17.56 years with male predominance (82%). Total of 7 patients required mechanical ventilation among whom the AIS chest was 3.0±0.82, ISS score was 29.14±6.89, and GCS 9.14±3.13. The ROC curve showed that ISS score predicted significantly about the requirement of mechanical ventilation with sensitivity of 85.5% and specificity of 99.8 %. CONCLUSION Initial CT done in patients can show the presence or absence of pulmonary contusion and associated thoracic injuries and along with AIS, ISS and GCS scores we can predict early the requirement of mechanical ventilation.

Morphometric Study of the Initial Ventricular Indices to Predict the Complications and Outcome of Aneurysmal Subarachnoid Hemorrhage

Acute hydrocephalus is a common complication in patients with aneurysmal subarachnoid hemorrhage (SAH). Several ventricular indices have been introduced to enable measurements of ventricular morphology. Previously, researchers have showed their diagnostic value for various neurological disorders. In this study, we evaluated the association between ventricular indices and the clinical course, occurrence of complications and outcome of SAH. A total of 745 SAH patients with available early admission computed tomography scans were included in the analyses. Six ventricular indices (bifrontal, bicaudate, ventricular and third ventricle ratios and Evans' and Huckman's indices) were measured. Primary endpoints included the occurrence of cerebral infarctions, in-hospital mortality and a poor outcome at 6 months. Secondary endpoints included different adverse events in the course of SAH. Clinically relevant cut-offs for the indices were determined using receiver operating curves. Univariate analyses were performed. Multivariate analyses were conducted on significant findings in a stepwise backward regression model. The higher the values of the ventricular indices were and the older the patient was, the higher the WFNS and Fisher's scores were, and the lower the SEBES score was at admission. Patients with larger ventricles showed a shorter duration of intracranial pressure increase > 20 mmHg and required decompressive craniectomy less frequently. Ventricular indices were independently associated with the parameters of inflammatory response after SAH (C-reactive protein in serum and interleukin-6 in cerebrospinal fluid and fever). Finally, there were independent correlations between larger ventricles and all the primary endpoints. The lower risk of intracranial pressure increase and absence of an association with vasospasm or systemic infections during SAH, and the poorer outcome in individuals with larger ventricles might be related to a more pronounced neuroinflammatory response after aneurysmal bleeding. These observations might be helpful in the development of specific medical and surgical treatment strategies for SAH patients depending on the initial ventricle measurements.

3D island sign on computed tomography predicts early perihematomal edema expansion and poor outcome in patients with intracerebral hemorrhage

Background and purposeTo determine the prognostics significance of the computed tomography (CT) 3D island sign for predicting early perihematomal edema (PHE) expansion and poor functional outcome in patients presenting with intracerebral hemorrhage (ICH). MethodsBetween July 2011 and March 2017, patients with intracerebral hemorrhage who had undergone baseline CT within 6 h after ICH symptom onsets and follow-up CT in our hospital were included. Two different readers independently assessed the presence of 3D island sign on admission CT scan of each patient. Multivariable logistic regression analysis was used to analyze association between 3D island sign and early perihematomal edema expansion and poor functional outcome, separately. ResultsA total of 214 patients who met the inclusion criteria were included in our study, 3D island sign was observed in 60 patients (28.0 %) on admission CT scan. The multivariate logistic regression analysis demonstrated that baseline hematoma volume, time to baseline and follow-up CT scans and the presence of 3D island sign were predictors of early PHE expansion. After adjusting for age, baseline hematoma and edema volume, time to baseline and follow-up CT scans, GCS on admission, presence of intraventricular hemorrhage (IVH) and systolic blood pressure, the 3D island sign was an independently imaging marker for poor outcome (OR, 2.803; 95 % confidence interval, 1.189–6.609; P = 0.018). ConclusionThe 3D island sign in patients with intracerebral hemorrhage was a reliable predictor for early perihematomal edema expansion and poor functional outcome. It may serve as a potential therapeutic target for intervention.

Radiographic and Clinical Predictors of Therapeutic Pelvic Angiography

Pelvic fractures are often complicated by hemorrhage contributing to morbidity and mortality. Management of these patients is multifaceted and computed tomography (CT) imaging plays an integral diagnostic role. The purpose of this study was to identify radiographic and clinical predictors of therapeutic angiography in patients with blunt pelvic fractures. All patients with blunt pelvic fractures who underwent angiography following admission CT scan were identified over a 6-year period. A radiologist reviewed the CT scans to identify potential predictors of pelvic hemorrhage. Patients were stratified by intervention [therapeutic angiography (TA) vs non-therapeutic angiography (NTA)] and compared. Multivariable logistic regression (MLR) was performed to determine independent predictors of TA. Youden's index was used to identify the optimal value of selected predictors identified on MLR. 177 patients were identified: 42% underwent TA and 58% underwent NTA. Patients undergoing TA were more likely to have a higher injury burden and greater resuscitative transfusion requirements, display both a brighter blush density on arterial phase CT and a larger % change in arterial to venous phase blush density. The optimal arterial blush density was determined to be 250 HU. MLR identified pre-angiography transfusion requirements (OR 1.175; 95% CI 1.054-1.311, P = .0189) and arterial blush density (OR 1.011; 95% CI 1.005-1.016, P < .0001) as independent predictors of therapeutic angiography. CT imaging remains vital in assessing patients with pelvic fractures and associated hemorrhage following blunt trauma. For patients requiring multiple resuscitative transfusions with CT findings of an arterial blush measuring ≥250 HU, early angiography should be the preferred approach.

HIPTCN: Prospective Observational Study of Hypocoagulated Head Trauma Patients with Normal Admission Computed Tomography Scan.

Our national protocol for traumatic brain injury dictates that hypocoagulated patients with mild trauma and initial tomographyscan with no intracranial traumatic changes must be hospitalized for 24 hours and do a post-surveillance tomography scan. Themain goal of this study was to evaluate the clinical relevance of these measures. A prospective observational study was undertaken in four hospitals. Adult hypocoagulated traumatic brain injurypatients with a normal tomography scan were included. The main outcomes evaluated were rate of delayed intracranial hemorrhage,rate of admission in a neurosurgical department, rate of complications related with surveillance and rate of prolonged hospitalizationdue to complications. An analysis combining data from a previously published report was also done. A total of 178 patients were included. Four patients (2.3%) had a delayed hemorrhage and three (1.7%) were hospitalizedin a neurosurgery ward. No cases of symptomatic hemorrhage were identified. No surgery was needed, and all patients had theiranticoagulation stopped. Complications during surveillance were reported in seven patients (3.9%), of which two required prolongedhospitalization. The rate of complications related with surveillance was higher than the rate of delayed hemorrhages. The initial period ofin-hospital surveillance did not convey any advantage since the management of patients was never dictated by neurological changes.Post-surveillance tomography played a role in deciding about anticoagulation suspension and prolongation of hospitalization. Delayed hemorrhage is a rare event and the need for surgery even rarer. The need for in-hospital surveillance should bereassessed.

Relationship Between Non-contrast Computed Tomography Imaging Markers and Perihemorrhagic Edema Growth in Intracerebral Hemorrhage.

Perihemorrhagic edema (PHE) growth has been gradually considered as predictor for outcome of Intracerebral hemorrhage (ICH) patients. The aim of our study was to investigate correlation between non-contrast computed tomography (CT) markers and early PHE growth. ICH patients between July 2011 and March 2017 were included in this retrospective analysis. ICH and PHE volumes were measured by using a validated semiautomatic volumetric algorithm. Nonparametric test was used for comparing PHE volume at different time points of non-contrast computed tomography (NCCT) imaging markers. Multivariable linear regression was constructed to study the relationship between NCCT imaging markers and PHE growth over 36h. A total of 214 patients were included. Nonparametric test showed that PHE volume was significantly different between patients with and without NCCT imaging markers. (all p < 0.05) In multivariable linear regression analysis adjusted for ICH characteristics, blend sign (p = 0.011), black hole sign (p = 0.002), island sign (p < 0.001), and expansion-prone hematoma (p < 0.001) were correlated with PHE growth. Follow-up PHE volume within 36h after baseline CT scan was associated with blend sign (p = 0.001), island sign (p < 0.001), and expansion-prone hematoma (p < 0.001). NCCT imaging markers of hematoma expansion are associated with PHE growth. This suggests that early PHE growth can be predicted using radiology markers on admission CT scan.

Systematic surgical exploration or observation and selective exploration of suspected traumatic mesenteric and bowel injuries: A meta-analysis

Context: Mesenteric and bowel injuries (MBI) are rare and dangerous presentations of blunt abdominal trauma and often cause clinical uncertainty since their diagnosis is difficult and operative treatments are often delayed. No clear guidelines exist regarding this topic, and due to the rarity of the injury, few and highly low-quality data are available. This study aimed to compare early surgical exploration, delayed surgical exploration, and non-operative management in patients with proven and suspected blunt MBI. Evidence Acquisition: Detailed research was performed on Medline, Embase, PubMed, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews databases until 29th November 2019. The studies that were considered eligible to be included in this systematic review and consequent meta-analysis were those focusing on patients with proven MBI or computed tomography (CT) signs suspected for them and comparing early surgical exploration (EOR) with delayed one (DOR) or with selective surgical exploration (SOR) after clinical observation. The eligible studies were sub-grouped into those using a delay cut-off (to distinguish “early” and “deferred” surgical intervention) higher than 12 h and those using a cut-off lower than 12 h, as well as those focusing on patients with high-risk CT signs (pneumoperitoneum and active mesenteric bleeding) and those focusing on patients with low-risk ones. Results: Finally, 16 studies fulfilled the inclusion criteria and were included in the meta-analysis with a total of 2,702 patients. All studies, although not randomized, were considered to be at the acceptable risk of bias in the important domains. It was found that in patients with proven MBI, in the subgroup of studies with a delay cut-off for surgical intervention lower than 12 h, the complication rate was significantly lower in EOR, compared to DOR (risk ratio [RR]=0.47, 95% CI=0.29-0.79, P=0.004). In patients with suspected MBI with low-risk CT signs, the complication rate was significantly lower in SOR, compared to EOR (RR=1.79, 95% CI=1.27-2.53, P=0.001). It was also revealed that in patients with high-risk CT signs, the complication rate and the length of stay (LOS) were significantly lower in EOR, compared to DOR (complication: RR=0.38, 95% CI=0.17-0.84, P=0.02; LOS: mean difference=-12.00, 95% CI=-21.44-2.56, P=0.01). Conclusions: The present meta-analysis confirmed that in patients with proven blunt MBI a delay of surgical intervention higher than 12 h would lead to a higher complication rate and a longer LOS. Based on the results, in blunt trauma patients with pneumoperitoneum or active mesenteric bleeding at the admission CT scan, complications and LOS could be reduced by performing an early surgical exploration. On the other hand, in blunt trauma patients with low-risk CT signs of suspected MBI, a clinical observation with selective surgical exploration in case of clinical or radiological worsening could reduce the complication rate without increasing mortality and LOS.

Point-of-Care Platform Blood Biomarker Testing of Glial Fibrillary Acidic Protein versus S100 Calcium-Binding Protein B for Prediction of Traumatic Brain Injuries: A Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study.

Glial fibrillary acidic protein (GFAP) is cleared by the Food and Drug Administration (FDA) to determine need for head computed tomography (CT) within 12 h after mild traumatic brain injury (TBI) (Glasgow Coma Score [GCS] 13-15); S100 calcium-binding protein B (S100B) serves this function in Europe. This phase 1 biomarker cohort analysis of the multi-center, observational Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study compares GFAP's diagnostic performance, measured on a rapid point-of-care platform, against protein S100B to predict intracranial abnormalities on CT within 24 h post-injury across the spectrum of TBI (GCS 3-15). Head CT scan performed in TBI subjects and blood was collected for all consenting subjects presenting to 18 United States level 1 trauma centers. Plasma was analyzed on a point-of-care device prototype assay for GFAP and serum was analyzed for S100B. In 1359 patients with TBI (GCS 3-15), mean (standard deviation [SD]) age = 40.1 (17.0) years; 68% were male. Plasma GFAP levels were significantly higher in CT+ TBI subjects (median = 1358 pg/mL, interquartile range [IQR]: 472-3803) than in CT- TBI subjects (median = 116 pg/mL, IQR: 26-397) or orthopedic trauma controls (n = 122; median = 13 pg/mL, IQR: 7-20), p < 0.001. Serum S100B levels were likewise higher in CT+ TBI subjects (median = 0.17 μg/L, IQR: 0.09-0.38) than in CT- TBI subjects (median = 0.10 μg/L, IQR: 0.06-0.18), p < 0.001. Receiver operating characteristic curves were generated for prediction of intracranial injury on admission CT scan; area under the curve (AUC) for GFAP was significantly higher than for S100B in the same cohort (GFAP AUC - 0.85, 95% confidence interval [CI] 0.83-0.87; S100B AUC - 0.67, 95% CI 0.64-0.70; p < 0.001). GFAP, measured on a point-of-care platform prototype assay, has high discriminative ability to predict intracranial abnormalities on CT scan in patients with TBI across the full injury spectrum of GCS 3-15 through 24 h post-injury. GFAP substantially outperforms S100B.

Effect of robotic rehabilitation on parameters of frequency analysis of EMG signal in children with cerebral palsy

Emergency laparotomy (EL) is an increasingly common procedure in the elderly. Factors associated with mortality in the subpopulation of frail patients have not been thoroughly investigated. Sarcopenia has been investigated as a surrogate for frailty and poor prognosis. Our primary aim was to evaluate the association between easily measured sarcopenia parameters and 30-day postoperative mortality in elderly patients undergoing EL. Length of stay (LOS) and admission to an intensive care unit were secondary end points.We conducted a retrospective cohort study, over a 5-year period, of patients aged 65 y and older who underwent EL at a tertiary university hospital. Sarcopenia was evaluated on admission computed tomography scan by two methods, first by psoas muscle attenuation and second by the product of perpendicular cross-sectional diameters (PCSDs). The lowest quartile of PCSDs and attenuation were defined as sarcopenic and compared with the rest of the cohort. Attenuation was stratified for the use of contrast enhancement. Multivariant logistic regression was performed to determine independent risk factors.During the study period, 403 patients, older than 65 y, underwent EL. Of these, 283 fit the inclusion criteria and 65 (23%) patients died within 30 d of surgery. On bivariate analysis, psoas muscle attenuation, but not PCSDs, was found to be associated with 30-day mortality (OR = 2.43, 95% CI = 1.34-4.38, P = 0.003) and longer LOS (35.7 d versus 22.2 d, Δd 13.5, 95% CI = 6.4-20.7, P < 0.001). In a multivariate analysis, psoas muscle attenuation, but not PCSDs, was an independent risk factor for 30-day postoperative mortality (OR = 2.35, 95% CI = 1.16-4.76, P = 0.017) and longer LOS (Δd = 14.4, 95% CI = 7.7-21.0, P < 0.001). Neither of the sarcopenia parameters was associated with increased admission to an intensive care unit.Psoas muscle attenuation is an independent risk factor for 30-day postoperative mortality and LOS after EL in the elderly population. This measurement can inform clinicians about the operative risk and hospital resource utilization.

Psoas Attenuation and Mortality of Elderly Patients Undergoing Nontraumatic Emergency Laparotomy

BackgroundEmergency laparotomy (EL) is an increasingly common procedure in the elderly. Factors associated with mortality in the subpopulation of frail patients have not been thoroughly investigated. Sarcopenia has been investigated as a surrogate for frailty and poor prognosis. Our primary aim was to evaluate the association between easily measured sarcopenia parameters and 30-day postoperative mortality in elderly patients undergoing EL. Length of stay (LOS) and admission to an intensive care unit were secondary end points. MethodsWe conducted a retrospective cohort study, over a 5-year period, of patients aged 65 y and older who underwent EL at a tertiary university hospital. Sarcopenia was evaluated on admission computed tomography scan by two methods, first by psoas muscle attenuation and second by the product of perpendicular cross-sectional diameters (PCSDs). The lowest quartile of PCSDs and attenuation were defined as sarcopenic and compared with the rest of the cohort. Attenuation was stratified for the use of contrast enhancement. Multivariant logistic regression was performed to determine independent risk factors. ResultsDuring the study period, 403 patients, older than 65 y, underwent EL. Of these, 283 fit the inclusion criteria and 65 (23%) patients died within 30 d of surgery. On bivariate analysis, psoas muscle attenuation, but not PCSDs, was found to be associated with 30-day mortality (OR = 2.43, 95% CI = 1.34-4.38, P = 0.003) and longer LOS (35.7 d versus 22.2 d, Δd 13.5, 95% CI = 6.4-20.7, P < 0.001). In a multivariate analysis, psoas muscle attenuation, but not PCSDs, was an independent risk factor for 30-day postoperative mortality (OR = 2.35, 95% CI = 1.16-4.76, P = 0.017) and longer LOS (Δd = 14.4, 95% CI = 7.7-21.0, P < 0.001). Neither of the sarcopenia parameters was associated with increased admission to an intensive care unit. DiscussionPsoas muscle attenuation is an independent risk factor for 30-day postoperative mortality and LOS after EL in the elderly population. This measurement can inform clinicians about the operative risk and hospital resource utilization.

Low Risk of Traumatic Intracranial Hematoma Expansion with Factor Xa Inhibitors without Andexanet Reversal

Andexanet alfa, a novel anticoagulation reversal agent for factor Xa inhibitors, was recently approved. Traumatic intracranial hemorrhage presents a prime target for this drug. The Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors study established the efficacy of andexanet alfa in reversing factor Xa inhibitors. However, the association between anticoagulation reversal and traumatic intracranial hemorrhage progression is not well understood. The objective of this study was to determine progression rates of patients with traumatic intracranial hemorrhage on factor Xa inhibitors prior to hospitalization who were managed without the use of andexanet alfa. A retrospective cohort study was performed between 2016 and 2019 at a single institution. An institutional traumatic brain injury (TBI) registry was queried. Patients with recorded use of apixaban or rivaroxaban <18 hours before injury were included. The primary study outcome was <35% increase in hemorrhage volume or thickness on repeated head computed tomography (CT) scans. We identified 25 patients meeting the inclusion criteria. Two patients were excluded because of a lack of necessary CT data. Twelve patients (52%) were receiving apixaban, and 11 were (48%) on rivaroxaban. On admission CT scan, 14 patients had subdural hematoma, 6 had traumatic intraparenchymal hemorrhage, and 3 had subarachnoid hemorrhage. Anticoagulation reversal was attempted in 17 patients (74%), primarily using 4-factor prothrombin complex concentrate. Twenty patients (87%) were adjudicated as having excellent or good hemostasis on repeat imaging. Our results indicate that patients on factor Xa inhibitors with complicated mild TBI have a similar intracranial hemorrhage progression rate to patients who are not anticoagulated or anticoagulated with a reversible agent. The hemostatic outcomes in our cohort were similar to those reported after andexanetalfa administration.

Radiographic predictors of therapeutic operative intervention after blunt abdominal trauma: the RAPTOR score.

Bowel and mesenteric injuries are rare in patients following blunt abdominal trauma. Computed tomography (CT) imaging has become a mainstay in the work-up of the stable trauma patient. The purpose of this study was to identify radiographic predictors of therapeutic operative intervention for mesenteric and/or bowel injuries in patients after blunt abdominal trauma. All patients with a discharge diagnosis of bowel and/or mesenteric injury after blunt trauma were identified over a 5-year period. Admission CT scans were reviewed to identify potential predictors of bowel and/or mesenteric injury. Patients were then stratified by operative intervention [therapeutic laparotomy (TL) vs. non-therapeutic laparotomy (NTL)] and compared. All potential predictors included in the initial regression model were assigned one point and a score based on the number of predictors was calculated: the radiographic predictors of therapeutic operative intervention (RAPTOR) score. 151 patients were identified. 114 (76%) patients underwent operative intervention. Of these, 75 patients (66%) underwent TL. Multifocal hematoma, acute arterial extravasation, bowel wall hematoma, bowel devascularization, fecalization, pneumoperitoneum and fat pad injury, identified as potential predictors on univariable analysis, were included in the initial regression model and comprised the RAPTOR score. The optimal RAPTOR score was identified as ≥ 3, with a sensitivity, specificity and positive predictive value of 67%, 85% and 86%, respectively. Acute arterial extravasation (OR 3.8; 95% CI 1.2-4.3), bowel devascularization (OR 14.5; 95% CI 11.8-18.4) and fat pad injury (OR 4.5 95% CI 1.6-6.2) were identified as independent predictors of TL (AUC 0.91). CT imaging remains vital in assessing for potential bowel and/or mesenteric injuries following blunt abdominal trauma. The RAPTOR score provides a simplified approach to predict the need for early therapeutic operative intervention.

Diffuse Intracranial Injury Patterns Are Associated with Impaired Cerebrovascular Reactivity in Adult Traumatic Brain Injury: A CENTER-TBI Validation Study.

Recent single-center retrospective analysis displayed the association between admission computed tomography (CT) markers of diffuse intracranial injury and worse cerebrovascular reactivity. The goal of this study was to further explore these associations using the prospective multi-center Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) high-resolution intensive care unit (HR ICU) data set. Using the CENTER-TBI HR ICU sub-study cohort, we evaluated those patients with both archived high-frequency digital physiology (100 Hz or higher) and the presence of a digital admission CT scan. Physiological signals were processed for pressure reactivity index (PRx) and both the percent (%) time above defined PRx thresholds and mean hourly dose above threshold. Admission CT injury scores were obtained from the database. Quantitative contusion, edema, intraventricular hemorrhage (IVH), and extra-axial lesion volumes were obtained via semi-automated segmentation. Comparison between admission CT characteristics and PRx metrics was conducted using Mann-U, Jonckheere-Terpstra testing, with a combination of univariate linear and logistic regression techniques. A total of 165 patients were included. Cisternal compression and high admission Rotterdam and Helsinki CT scores, and Marshall CT diffuse injury sub-scores were associated with increased percent (%) time and hourly dose above PRx threshold of 0, +0.25, and +0.35 (p < 0.02 for all). Logistic regression analysis displayed an association between deep peri-contusional edema and mean PRx above a threshold of +0.25. These results suggest that diffuse injury patterns, consistent with acceleration/deceleration forces, are associated with impaired cerebrovascular reactivity. Diffuse admission intracranial injury patterns appear to be consistently associated with impaired cerebrovascular reactivity, as measured through PRx. This is in keeping with the previous single-center retrospective literature on the topic. This study provides multi-center validation for those results, and provides preliminary data to support potential risk stratification for impaired cerebrovascular reactivity based on injury pattern.

Testing the clinical validity of the Bemelman Rib Fracture Management Guideline.

Whilst surgical stabilization of rib fractures (SSRF) results in better outcomes, selection algorithms are lacking. We aimed to validate the Rib Fracture Management Guideline proposed by Bemelman. From a cohort of 792 patients with multiple rib fractures, 2 sequential cohorts were selected: 48 patients who underwent SSRF and 48 patients who managed conservatively. Admission computed tomography scans and records were reviewed by an investigator blinded to the SSRF outcome. Adherence to the Bemelman guideline, revised to take account of consensus rib fracture definitions, was tested. Fifty-seven patients had multiple rib fractures only, and 39 patients also had a flail segment. Thirty-nine patients with flail segment underwent SSRF, and 18 patients were managed conservatively. Of the patients that the guideline predicted should have received surgery, 87% did. Of those that it predicted should not receive SSRF, 98% did not. The guideline displayed a sensitivity (95% confidence interval) and specificity for predicting the fixation of 0.98 (0.89-0.9995) and 0.83 (0.70-0.93), respectively. The positive and negative predictive values for surgical fixation were 0.87 (0.76-0.92) and 0.98 (0.85-0.99), respectively. The Bemelman guideline was thus a good predictor of SSRF in retrospective cohort but should be used in conjunction with clinical judgement. Further validation is indicated in a prospective study.

Modeling variability in the inferior vena cava into fenestrated endografts for retrohepatic caval injuries

ObjectiveInjury of the retrohepatic inferior vena cava (IVC) is rare, but extremely fatal. Open repair of these injuries is challenging. Various maneuvers, including atriocaval shunting and total vascular isolation, have been described, but are poorly tolerated in the severely injured patient. Endovascular repair is an attractive alternative strategy, but effective hemostasis of complex injuries requires an endograft that excludes the injury while permitting flow from the hepatic veins. Unfortunately, IVC and hepatic vein anatomy is highly variable and has not been clearly described in injured patients. Our purpose was to characterize critical human IVC morphology in trauma patients, and develop the design parameters of an off-the-shelf fenestrated endograft intended for caval deployment. MethodsOne hundred consecutive adult trauma patients with an admission computed tomography scan including a portal venous phase of the abdomen were reviewed. Specific anatomic measurements including segmental IVC lengths and diameters were obtained. Multiple theoretical endografts were modeled to optimize caval coverage in the retrohepatic segment, assuming 10% to 40% oversizing for seal. ResultsThis sample population had a mean age of 50 years, height of 173 cm, and weight 84 kg. Seventy-one percent were male and 89% had a blunt mechanism of injury. The median caval length from the renal veins to right atrium was 111 mm (interquartile range [IQR], 102-120 mm), diameter was 22 mm (IQR, 19-26 mm), and hepatic venous orifice area was 336 mm2 (IQR, 267-432 mm2). All patients had a landing zone of at least 12 mm in the suprahepatic and 10 mm in the suprarenal segments. Three models of graft length were developed to accommodate patients with segmental and overall dimensions in the smallest half, third quartile, and fourth quartile. These could provide 95% of patients with coverage of the retrohepatic segment without risk of hepatic or renal vein occlusion. Four graft diameters were developed for cross-sectional fit. Graft diameters of 20, 24, 30, and 38 mm could provide adequate coverage in, respectively, 11%, 35%, 49%, and 16% of patients. These combinations of graft length and diameter would accommodate 93% of patients. ConclusionsWe defined human IVC morphology essential for endovascular therapy and developed parameters for fenestrated IVC endografts to address retrohepatic caval injuries in trauma patients. Although additional study and testing are required, this proof-of-concept study supports the hypothesis that exclusion of the most devastating retrohepatic IVC injuries can be achieved with a reasonable number of off-the-shelf fenestrated endografts. These findings form the basis for additional research toward the development of novel devices for endovascular therapy of these often lethal injuries.